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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005601
Report Date: 01/17/2025
Date Signed: 01/17/2025 11:26:57 AM

Document Has Been Signed on 01/17/2025 11:26 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:DE SILVA, NIROSHAFACILITY NUMBER:
214005601
ADMINISTRATOR/
DIRECTOR:		DE SILVA, NIROSHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 827-7477
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 1DATE:
01/17/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Nirosha De SilvaTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
NARRATIVE
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On January 17, 2025 Licensing Program Analysts (LPAs) Nathan Garcia and Katie Krenn conducted an unannounced, plan of correction visit (POC) to the facility. LPA's met with licensee, Nirosha De Silva, and explained the purpose of the visit. Present during LPA’s visit included 1 infant child in care with the licensee and her husband.

On October 08, 2024, LPA Garcia conducted an unannounced, annual visit at facility. During the visit, LPA issued multiple citations issued such observation an infant child with a pacifier with a string attached. The licensee immediately removed the pacifier during the visit and the citation was cleared. The other citations include missing 15 minute sleep logs, mandated reporter training certificates and proper documentation of children's records. A plan of correction and signed LIC9224 were discussed with Licensee.

Plan of correction were discussed with licensee to be compliant and meet the regulations.
Licensee states that she only cares for only 1 child and all the children's records are completed. LPAs requested the licensee for the facility roster and licensee updated the roster during the visit. Licensee also states that she plans to close the facility in the future. LPAs gave her direction on how she can accomplish that when she's ready to do so.

As of today's POC visit, the licensee is in compliance with a verifiable mandated reporter training certificates, sleep logs, and children's records are in order. Deficiencies cited on 10/8/24 are cleared during the visit. LPAs observed that the LIC 9224 is not signed.

Type B deficiency cited during today's visit for unsigned LIC 9224. Notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with licensee, Nirosha De Silva.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/17/2025 11:26 AM - It Cannot Be Edited


Created By: Nathan Garcia On 01/17/2025 at 11:09 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DE SILVA, NIROSHA
FACILITY NUMBER: 214005601

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2025
Section Cited
HSC
1596.8595

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1596.8595(a)1 Posting licensing report by child care facility or home; duration of posting; civil penalty for failure to comply; reports to be provided to parents or guardian of each child receiving services.

Each licensed child day care facility shall post a copy of any licensing report pertaining to the facility that documents either a facility visit or a complaint investigation that results in a citation for a violation that, if not corrected, will create a direct and immediate risk to the health, safety, or personal rights of children in care. The licensing report provided by the department shall be posted immediately upon receipt, adjacent to the postings required pursuant to Section 1596.817 and on, or immediately adjacent to, the interior side of the main door to the facility and shall remain posted for 30 consecutive days.

This requirement has not been met as evidenced by:
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The licensee will get the LIC 9224 signed by the authorized representative by set due date.
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Based on today's visit, LPAs observed during file review that the licensee did not get the LIC 9224 document signed by the authorized representative.
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Licensee will send the document to LPA through email or text.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Daniel J Oquendo
LICENSING EVALUATOR NAME:Nathan Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025


LIC809 (FAS) - (06/04)
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